Archive for the ‘Healthcare’ Category

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Income Disparities Impact Healthcare Availability

Monday, April 2nd, 2012

There are limited affordable choices for Americans who do not have health insurance through their jobs, especially for those with low and moderate incomes.  Few are Medicaid-eligible, and locating a plan on the individual market equals paying high premiums.  According to the Commonwealth Fund Health Insurance Tracking Survey of U.S. Adults, 2011, nearly 57 percent of adults aged 19 to 64 in families earning less than 133 percent of the federal poverty level ($29,726 for a family of four) were uninsured for a time in 2011 and 41 percent) were uninsured for a year or longer.  In contrast, only 12 percent of adults earning 400 percent of poverty or more ($89,400 for a family of four) were uninsured during the year, with four percent having no healthcare insurance for one year or longer.

The lack of health insurance significantly makes it difficult to get needed healthcare.  Low- and moderate-income adults who were uninsured in 2011 were much less likely to have a regular source of healthcare than those who did have insurance.  Additionally, uninsured low- and moderate-income adults were more likely to cite factors other than medical emergencies as reasons for going to the emergency room.  These included needing a prescription drug or lacking a regular primary-care physician.

The survey also demonstrates how vital Medicaid and the Children’s Health Insurance Program (CHIP) are in providing health insurance to children in low- and moderate-income families.  More than 63 percent of adults with children under 133 percent of the poverty level and nearly 38 percent with incomes between 133 percent and 249 percent of poverty said that some or all of their children were covered by either program.  The Patient Protection and Affordable Care Act (ACA) will expand the ability of Medicaid and CHIP to cover children and families by targeting adults in low- and moderate-income families who are at the greatest risk of lacking health benefits through a job.

When it becomes fully effective in 2014, the ACA will provide near-universal health insurance through a broad expansion of Medicaid, premium tax credits that cap premium contributions as a share of income for people purchasing private health plans through new state insurance exchanges.  Another benefit is new insurance market rules that prevent health insurers from denying coverage or charging people with pre-existing medical conditions higher premiums.

Or, as the Washington Post’s Sarah Kliff puts it, “While the private insurance expansion could get thrown into limbo by the Supreme Court, there’s pretty widespread agreement that, absent full repeal of the bill, health reform’s Medicaid expansion is here to stay.  And that means a wide-reaching expansion of the entitlement program about two years from now.”

According to the Commonwealth Fund’s analysis, as a result of the Affordable Care Act, the majority of the 52 million adults who did not have health insurance in 2010 will gain coverage beginning in 2014.  Millions more will benefit as their ability to afford the price of premiums and out-of-pocket costs improves.

Karen Davis, President of the Commonwealth Fund, said that “The silver lining is that the Patient Protection and Affordable Care Act has already begun to bring relief to families.  Once the new law is fully implemented, we can be confident that no future recession will have the power to strip so many Americans of their health security.”

Amanda Peterson Beadle, writing on the thinkprogress.org website, notes that “The Affordable Care Act has already expanded health insurance to 2.5 million 19-to-25 year-olds, banned lifetime limits on health insurance coverage, created pre-existing condition insurance plans providing health insurance options to those who were often uninsurable, and required insurers to cover preventive care without requiring co-payments.  But the major provisions of the law to be implemented in 2014 will have the biggest effect on narrowing the income divide.”

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$1,000 Toothbrushes and $140 Tylenols: And You’re Footing the Bill

Thursday, March 29th, 2012

As the debate about the future of Medicare heats up, the program’s chief actuary estimates that 15 percent to 30 percent of healthcare expenditures are wasteful. Cindy Holtzman, a consumer advocate with Medical Billing Advocates of America, cited several examples, such as a Florida patient who was charged $140 for a single Tylenol.  A patient in South Carolina paid $1,000 for a toothbrush.  A patient in Georgia who used one bag of IV saline solution was billed for 41 bags for a total of $4,000.  In the case of the Georgia patient, insurance paid the entire claim.  “Usually any kind of bill under $100,000, they (insurance companies) don’t look at the details.  And that’s where something like this can be paid in error,” Holtzman said.  After Holtzman investigated, the bill was fixed, and the insurance company was refunded its money.

Medicare spending exceeded $500 billion in 2010.  As much as $75 billion to $150 billion could be cut without reducing needed services.  A potential cause is that Medicare’s reimbursement procedures do not track the appropriateness of the care provided.  Medicare farms out its claims administration to private local contractors based on how quickly and cheaply they process claims.  These contractors are not given incentives to audit the taxpayer dollars they spend; even if they wanted to, they would need data that is typically not found on the claim form.

Healthcare spending is wasteful across the board, not just in Medicare.  Writing for Politico, Ralph G. Neas, CEO of the National Coalition on Health Care (NCHC), a non-profit, non-partisan organization working to improve America’s healthcare system, says that “Total expenditures on healthcare represented 17 percent of the gross national product in 2010 and are projected to reach 20 percent by the end of this decade.  The federal government already spends more for health care than for defense, Social Security or any other single spending category.  The nonpartisan Congressional Budget Office has emphatically identified rising health costs as the greatest threat to our fiscal future.  It doesn’t have to be this way.  Our current system is devastatingly inefficient.  The United States spends 141 percent more on healthcare than other economically advanced nations.  But our far higher bill is not buying us a healthier population.  Roughly 30 percent to 40 percent of medical and hospital costs can be attributed to waste and inefficiency.  That means, America is on a path to squander $10 trillion over the next decade. That hemorrhage would leave our economy — and our cities, states, small businesses and middle-class families — on life support.  Given our financial condition, preventing this kind of spending and the economic drag it represents should be the kind of urgent national problem that overrides ideological differences and encourages us to find common purpose.”

NEHI, an independent non-profit national network for health innovation, has recommended actions that would reduce wasteful healthcare spending by up to $84 billion. The plan was produced in collaboration with the National Priorities Partnership.  One major area for savings is eliminating emergency department overuse.  More than half of the 120 million annual ED visits can be avoided, representing a $38 billion opportunity for savings.  Medication errors add up to seven million inpatient admission and outpatient visits involving serious but avoidable medication errors, representing a $21 billion opportunity for savings.  Unnecessary hospital readmissions is another area where savings can be achieved.  Seven million people are readmitted to hospitals within 30 days of discharge annually but 836,000 of these cases could be avoided, representing a $25 billion opportunity.

Another study believes that healthcare spending waste is much more widespread.  As much as 50 cents of every dollar spent in healthcare is wasted, according to Pricewaterhouse Cooper’s Research Institute. The organization determined that unnecessary price gouging makes up $1.2 trillion of the $2.2 trillion spent on healthcare nationwide.  “Our best estimate is that for the country as a whole, probably half of what we’re spending on healthcare delivery today is technically waste from a patient’s perspective,” said Dr. Brent James, chief quality officer for Intermountain Healthcare in Salt Lake City.  “There are better ways of doing it.”

The Institute of Medicine (IOM), a division of the non-partisan National Academy of Sciences, reports that “excess costs” – which translates to waste — in the American healthcare system cost $810 billion every year. Their findings?  Overly-high insurance administrative costs absorbed by doctors and hospitals cost $190 billion.  Insurance company inefficiencies cost $20 billion.  Unnecessary services (brand name drugs instead of generics, repetitive tests and procedures, etc.) cost $210 billion.  Too-high prices for doctors and hospitals cost $85 billion.  High drug and device prices cost $20 billion.  Errors and avoidable complications cost $75 billion.  Inefficient delivery of services costs $ 80 billion.  Fraud costs $75 billion.  Missed disease-prevention opportunities cost $55 billion.

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CMS’ Value-Based Purchasing Program Is In the Works

Wednesday, March 28th, 2012

The Department of Health and Human Services (HHS) is formulating a new initiative to reward hospitals for the quality of care they provide to Medicare patients and reduce healthcare costs.  Authorized by the Patient Protection and Affordable Care Act (ACA), the Hospital Value-Based Purchasing program marks an historic change in how Medicare pays healthcare providers and facilities — for the first time, 3,500 hospitals nationwide will be paid for inpatient acute-care services based on care quality, not just the quantity of the services they provide.

This initiative supports the objectives of the Partnership for Patients, a public-private partnership that will help improve the quality, safety and affordability of health care for all Americans.  The partnership has the potential to save 60,000 lives and up to $35 billion in U.S. healthcare costs over the next three years, including up to $10 billion for Medicare.  Over the next ten years, the Partnership for Patients could reduce costs to Medicare by about $50 billion and result in billions more in Medicaid savings.

“Changing the way we pay hospitals will improve the quality of care for seniors and save money for all of us,” said HHS Secretary Kathleen Sebelius.  “Under this initiative, Medicare will reward hospitals that provide high-quality care and keep their patients healthy. It’s an important part of our work to improve the health of our nation and drive down costs.  As hospitals work to improve their performance on these measures, all patients – not just Medicare patients – will benefit.”

The Hospital Value-Based Purchasing initiative is just one part of a broad effort by the Obama Administration to improve the quality of health care for all Americans, using important new tools provided by the ACA.  The Partnership for Patients brings together hospitals, doctors, nurses, pharmacists, employers, unions, and state and federal government committed to keeping patients from getting injured or sicker in the health care system and improving transitions between care settings.  The Centers for Medicare and Medicaid Services (CMS) is investing up to $1 billion to drive these changes.  Additionally, proposed rules allowing Medicare to pay new Accountable Care Organizations (ACOs) to improve coordination of patient care are also expected to result in better care and lower costs.

In essence, the program rewards hospitals that perform well on quality measures relating both to clinical process of care and to patient experience of care, or those making improvements in their performance on those measures.  Hospitals that meet performance criteria will receive higher compensation.  The hospital value-based purchasing program, which is expected to become effective in fiscal 2013 for payments for discharges occurring on or after October 1, 2012, would make value-based incentive payments based on how much the hospitals’ performance improves certain quality measures during a baseline timeframe.  The better a hospital’s performance or improvement during the performance period, the higher the hospital’s value-based incentive payment would be, according to CMS.

According to CMS estimates, approximately 50 percent of the facilities participating in this Hospital Inpatient Value-Based Purchasing program will receive a net increase in their Medicare payments.  The other half will see a net decrease.  Neither the increase nor the decrease will exceed one percent in the first year, CMS said.  The better-performing hospitals in the first year have the potential to receive value-based incentive payments totaling as much as two percent of Medicare reimbursement, or a net one percent extra,  CMS sees the program as “the next step in promoting higher quality care for Medicare beneficiaries.”  When the program gets underway, CMS said, the government will reward hospitals on the basis of “actual quality performance,” and not just data.

Jean Moody-Williams, director of the Quality Improvement Group within CMS’ Office of Clinical Standards and Quality, said the Hospital VBP Program is funded by a one percent withholding from participating hospitals’ diagnosis-related group (DRG) payments; hospitals excluded from the program will not have that one percent withheld from their DRG payments.  “The goal of CMS through the Hospital Value-Based Purchasing Program is to link payments to quality outcomes,” Williams said.  “We really are starting to get away from asking, ‘How much did you do?’ to ‘How well did you do and how was it for the patient?’”

The American Hospital Association (AHA) has serious reservations about the program, noting that “CMS has not met its requirements with respect to certain measures.  This failure will unfairly and adversely impact the hospital field and even undermine the intent of the law, which is to provide opportunities for hospitals to improve their performance.”

According to the AHA, the problem “is exacerbated in the outpatient PPS (prospective payment system) rulemaking cycle because it builds on policies that fail to comply with the law’s requirements.” AHA also expressed concern with how the agency handled the notice and comment process for the hospital VBP program, which “made significant changes to this program in three separate regulations,” and suggested that the agency choose a single regulation in which it will make any future changes to the program.

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The Supreme Court Takes on the ACA

Tuesday, March 27th, 2012

As the Supreme Court begins three days of hearing about the constitutionality of the Patient Protection and Affordable Care Act (ACA), Americans have mixed feelings about President Barack Obama’s signature healthcare overhaul.  The individual mandate is extremely unpopular, despite the fact that approximately 80 percent of Americans have healthcare coverage through workplace plans or government insurance such as Medicare and Medicaid.  When the insurance obligation kicks in, the majority of Americans won’t need to buy anything new.  The bottom line appears to be that Americans object to being told how to spend their money, even if it solves the dilemma of the nation’s more than 50 million uninsured.  One critic dismissed the individual mandate by saying “If things were that easy, I could mandate everybody to buy a house and that would solve the problem of homelessness.”

Listen to Republicans describe the law as an attack on personal freedom, and you’d be surprised to learn that the idea originated with them.  Its model is the Massachusetts law enacted in 2006 when Mitt Romney was the governor.  Former House Speaker Newt Gingrich supported an individual mandate as an alternative to President Bill Clinton’s healthcare proposal, which put the burden on employers.  All four GOP candidates have promised to repeal the Affordable Care Act, which they describe as “Obamacare.”  Former Senator Rick Santorum (R-PA) terms it “the death knell for freedom.”

President Obama and congressional Democrats passed the mandate in 2010, without Republican support, in an effort to create a fair system that assures that all Americans — whether rich or poor, young or old — get the healthcare they need.  One thing that proponents point out is that other economically advanced countries have succeeded at it.  Congress determined that when the uninsured visit a clinic or the emergency room, the care they can’t afford costs roughly $75 billion a year.  A large percentage of that cost ends up adding $1,000 a year to the average family’s insurance premium.

In legal briefs challenging the law, opponents contend that the “minimum coverage requirement” — known as the individual mandate — would set a precedent that could apply to literally anything.  If it’s legal for Americans to be told to buy health insurance, Congress could try to impose “a broccoli mandate, a car-purchase mandate, really any other mandate that you’d want,” said Ilya Somin, a law professor at George Mason University.  “There are lots of interest groups that would love to lobby Congress to require people to buy their products.”

The mandate is intended to ensure that new insurance market reforms in the law work as intended.  Unless younger, healthier people — who often don’t purchase insurance until they get sick — are covered, the costs of those changes would be exorbitant.  In response to opponents’ admonitions that a mandate to buy insurance could lead to other government-required purchases, the Obama administration argued that no such examples exist.  “Respondents acknowledge that states do have the power to enact purchase mandates, but they identify no example of any state ever having compelled its citizens to buy cars, agricultural products, gym memberships or any other consumer product,” according to the Obama administration.

Not surprisingly, 73 percent of Americans believe that the Supreme Court will be influenced by politics when it rules on the constitutionality of the ACA.  The attitude crosses party lines and is particularly popular with independent voters, of whom 80 percent believe that the court will not base its ruling strictly on its legal merits, according to a Bloomberg National Poll.  Seventy-four percent of Republicans and 67 percent of Democrats believe that politics will be a determining factor in the court’s healthcare decision.

“I always worry when the court steps into the political thicket,” said Barbara Perry, a Supreme Court scholar and professor at the University of Virginia in Charlottesville.  “It does so at its peril.”  The justices themselves say that politics doesn’t impact their decisions.  “It is a very serious threat to the independence and integrity of the courts to politicize them,” Chief Justice John Roberts said at his 2005 Senate confirmation hearing.  Justice Stephen Breyer told Bloomberg News that politics doesn’t influence the court, even in cases with electoral implications.  “It would be bad if it were there,” he said.  “And I don’t see it.”

In reviewing the ACA, the Supreme Court is entering territory that it hasn’t approached since the days of Franklin Delano Roosevelt: ruling on a president’s signature legislative victory in the midst of his re-election campaign.  Justices are taking more time to listen arguments — six hours over three days — than any other case in the last 44 years.   “This is a central challenge to the modern Constitution, which was fashioned during the New Deal and then elaborated further during the civil rights revolution,” said Bruce Ackerman, a professor at Yale Law School in New Haven, Connecticut and author of The Decline and Fall of the American Republic.  “This goes to the very foundations of modern American government.”

The closest comparable was 76 years ago, involving Roosevelt’s New Deal, a response to the Great Depression.  It wasn’t a single piece of legislation and included the creation of Social Security.  The court ruled against parts of the New Deal, while leaving others in place.  The principal decision came when the court struck down much of the National Industrial Recovery Act, which allowed industries to create trade associations that set quotas and fixed prices.

Those wishing to tune in and watch the excitement are destined to be disappointed. The Supreme Court will make available same-day audio of the oral arguments.  In its announcement, the court said it is making the audio available because of the “extraordinary public interest” in the case.

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Mitt Romney Says “No” to Medicare on His 65th Birthday

Monday, March 19th, 2012

Even though he just celebrated his 65th birthday, GOP presidential hopeful Mitt Romney isn’t signing up for Medicare or Social Security.  According to an aide, Romney plans to keep his private health insurance plan although there is no word on whether he accessed that plan through a former employer or bought it on the individual market.  Ironically, if elected, Romney wants to offer senior citizens the choice of enrolling in the traditional program or purchasing private insurance with some financial help from the government.

Romney’s decision puts him in a tiny minority. The vast majority of seniors participate in Medicare.  Nearly all seniors are automatically enrolled in Medicare Part A, which covers hospital care, although they can opt not to use it.  Another 95 percent enroll in Medicare Part B, which covers physician services, according to the Kaiser Family Foundation.

“It was personally meaningful in me to be enrolling in the program I ran.  It made me feel one step closer to the beneficiaries,” Dr. Donald Berwick, who left his post at the Centers for Medicare and Medicaid Services (CMS) at the end of 2011, said.  “It validated what I had thought — which was that it was remarkably easy [to sign up].  Any president, at any age, should be committed to these important programs,” Berwick said.

By contrast, two of Romney’s competitors — Newt Gingrich and Ron Paul — are already 65, the age at which most Americans become eligible to enroll in Medicare’s coverage of hospital treatment, physician visits and other medical care, including prescription drugs.  Gingrich has a Medicare Advantage plan, administered by Blue Cross Blue Shield, according to his campaign.  Medicare Advantage plans are run by private insurance companies, who receive a fixed monthly payment from the federal government.  Gingrich frequently plugs Medicare Advantage and wants to expand the proportion of seniors who enroll in it from the current 25 percent.  Congressman Paul has a federal government-sponsored Blue Cross Blue Shield employee health insurance plan.  He has said that he would not change any aspect of Medicare for current beneficiaries but would let younger people opt out of the program and use medical savings accounts or other ways to pay their own healthcare costs.

According to NPR’s Julie Rovner, “Romney is clearly making a political point.  Wealthy people like him ought to pay more for their Medicare benefits (if they get them at all) and that perhaps 65 is a little young to qualify, too.  ‘Wealthier seniors will receive less support,’ under the changes Romney has proposed for Medicare, according to his website. http://www.mittromney.com/issues/medicare At the same time, he is proposing to ‘gradually raise the retirement age to reflect increases in longevity.’  But could his political point cost him more down the road if he changes his mind?  Maybe.  Medicare charges penalties for those who wait to sign up.  It’s the program’s way of ensuring that people don’t wait until they get sick to enroll.”

Beneficiaries currently have a seven-month window to sign up for Medicare: three months before their birth month, the month of their birthday, and three months after their birthday.  That means that Romney has through June to enroll if he changes his mind.  The majority of adults use the Social Security Administration website to enroll for their benefits, while others go to local district offices.

Writing for the Huffington Post, Ethan Rome, Executive Director of Health Care for America Now, says that “I’m not sure what Romney’s trying to prove, but what his action says is clear: I’m not like the Americans who enroll in Medicare.  I’m special.  I’m rich.  I’m better than you.  Ask yourself: If Romney doesn’t need or want Medicare for himself, will he protect it for the rest of us who do?  Of course not.  Instead, he’ll continue to support the Republican plan to eliminate Medicare as we know it.  He’ll work to turn Medicare into a voucher program that will saddle seniors with thousands of dollars in out-of-pocket health care costs.  Because, after all, what senior can’t afford to spend an extra $6,400 a year on doctors and hospitals?  Before Medicare, seniors were left at the mercy of the private market and therefore virtually uninsurable.  Without insurance, even brief hospital stays could impoverish them.  The result was that the elderly went without the care they needed — unless their families were rich.  Most seniors were one illness away from bankruptcy.”

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EHR Adoption Moving Forward

Wednesday, March 14th, 2012

The nation’s hospitals must demonstrate that they have collected the vital statistics of more than 80 percent of their patients in digital form if they want to continue receiving as much as $14.6 billion in federal grants for installing electronic health records (EHR) technology.  Awards as large as $11.5 million are available to hospitals that can prove “meaningful use” of the equipment, under preliminary rules issued by the Obama administration.  Physicians can apply for grants of $44,000 or $64,000, depending on whether they treat patients in Medicare or Medicaid.

The rules continue carrying out an initiative in the American Recovery and Reinvestment Act (ARRA) as a step toward overhauling the nation’s healthcare system, specifically in the Health Information Technology for Economic and Clinical Health (HITECH) Act.  Hospitals and doctors should achieve “substantial benefits” from adopting digital records, including lower record-keeping costs, fewer pointless tests, shorter hospital stays and reduced medical errors.

The percentage of U.S. hospitals that have adopted electronic records more than doubled between 2009 and 2011, to 35 percent, according to the American Hospital Association.  Approximately 85 percent of hospitals told the association that they plan to take advantage of government incentives by 2015.  The government expects that by 2019, 96 percent of hospitals will adopt electronic records and at least 36 percent of doctors’ practices.

In this second stage of adoption of EHR, the government is emphasizing making sure that electronic systems can talk to one another – or are “interoperable.”  According to Kaiser Health News, it’s “a real push ahead,” said Farzad Mostashari, the national coordinator for health information technology.  The rules require systems be able to transfer patient information across platforms.  A “summary of care” — including past diagnoses, procedures and test results – must be able to follow patients across referrals and changes in health care provider.  Additionally, the information should be available to some patients, who under Stage 2 requirements must be allowed to view their records online, as well as download and transfer information.  Finally, some patients must be able to communicate with their doctors through a secure, online system.

According to a survey of 302 hospital IT executives, more than one-quarter said they had already proven to the Centers for Medicare and Medicaid Services (CMS) that they have met the government’s standard for the first stage of meaningful use of health IT.  That means they have demonstrated that they have the baseline capabilities in their CMS-approved health IT system to collect and submit data.  Stage 2 also deals with security of exchanging patient information electronically, particularly the risk of a doctor mistakenly leaving his laptop or iPad accessible to the public.  “A huge, huge, huge portion of all breaches don’t occur because someone hacked into the system; they occur because people left their laptop on the train and they didn’t encrypt it,” Mostashari said.

Writing on the practicefusion.com website, Robert Rowley, M.D., says that “Stage 2 is about connectivity.  So let us take a step back and re-assess the larger picture.  Stage 1 Meaningful Use is about adoption of EHRs into the daily practice of clinicians and hospitals.  It is about moving the documentation of healthcare away from paper, and onto a digital platform.  The platform didn’t really have to connect with anything, though the capability to connect needs to be built for the technology to be Certified.  Stage 2 is about connectivity.  Now that EHRs are adopted, implemented and used meaningfully, the next stage is intended to be about connecting the silos together.  Stage 3, to come later, will be about inserting Decision Support between the connections, so that best practices (as well as authorizations) become part of the daily fabric of healthcare.”

A little-known fact is that EHR adoption is having a positive impact on healthcare IT job creation.  According to job resource Medzilla, an estimated 50,000 new jobs have been created in the health IT field since 2009, when the government passed the HITECH Act, which authorized funding for the EHR incentive program.  “The statistics over the past few months have been more than encouraging,” said Del Johnson, director of client relations at Medzilla.  “Here you have two, previously separate industries that are rapidly growing into one another.  Where the two meet you have an opportunity to explore a completely new labor pool.”

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Physician, Patient Must Share in Decision Making

Monday, March 12th, 2012

Heart devices save lives, but too often make the patient miserable.  That unpleasant possibility is why physicians are being urged to talk more honestly with people who have very weak hearts and are considering pumps, pacemakers, new valves or procedures to clear clogged arteries.  Patients with advanced heart failure often don’t realize what they are getting into when they agree to a treatment, and doctors assume they want everything possible done to keep them alive, according to the American Heart Association. The directive recommends shared decision making when patients face chronic conditions that frequently prove fatal; they need to decide what they really want for their remaining days.  If they also have dementia or kidney failure, the answer may not be a heart device.

“Patients may feel that the treatment was worse than the disease,” said Dr. Larry Allen of the University of Colorado Anschutz Medical Center, who helped draft the new advice. One of Dr. Allen’s former patients was a 74-year-old man too weak to shop or take walks.  He was so despondent that physicians thought he would feel better with a “mini artificial heart” — a $100,000 left ventricular assist device to improve his heart’s ability to pump blood.  “Even if it goes well, people are left with an electrical cord coming out of their belly” and a higher risk of stroke and bleeding from the nose or throat, Allen said.

More than five million Americans suffer heart failure, and the number is increasing as the population ages.  More and more high-tech treatments treat advanced disease, but they usually don’t slow its progression, they just keep people alive.  And that means living longer with symptoms that do nothing but worsen.  Patients typically don’t understand the repercussions when they agree to gadgets like a $30,000 to $50,000 implanted defibrillator, which shocks a quivering heart back into normal rhythm.  “Defibrillators don’t actually make people feel better — it doesn’t treat the underlying heart failure.  All it does is abort sudden death,” Allen said.

Allen and other physicians involved in the study stressed the importance of building a patient-doctor consensus with respect to questions of survival, symptom relief and quality of life issues.  Depending on their personal situation, not all patients want to “do everything” at all costs.  One way to facilitate such a discussion, according to the authors, is to reserve one day a year to review the patient’s situation, focusing on prognosis and possible treatments alongside an appreciation for the patient’s values and goals.  This annual review is not intended to replace appropriate discussions about the patient’s ongoing care, such as when a turn for the worse or hospitalization occurs.  “The process of checking in with patients on a regular basis is extremely important because heart failure and general health change over time,” Allen said.

Shared decision making goes beyond informed consent, requiring that healthcare providers and patients consider information together and work toward consensus.  This process should focus on the outcomes that are most important to the patients, including not only survival but also relief of symptoms, quality of life and living at home.  “For patients with advanced heart failure, the decision-making process should be proactive, anticipatory, and patient-centered. This involves talking about goals of care, expectations for the future, and the full range treatment options, including palliative care,” according to Dr. Allen.

Because the time required for shared decision making is tricky to fit into a regular clinic visit, the authors suggest a yearly review to discuss prognosis, consider realistic therapies, and spell out the patient’s values, goals and preferences.  This review is in addition to discussions triggered by events such as hospitalizations and other changes in the patient’s health.  “The process of checking in with patients on a regular basis is extremely important because heart failure and general health change over time,” Dr. Allen said.

Heart failure typically progresses with time.  During the early stages, it can often be managed with medicines and lifestyle changes in diet, stopping smoking and exercise.  Advanced heart failure requires additional treatments, including heart transplantation.  A focus of the decision making process is understanding that “doing everything” is not always the best thing.  For many patients with advanced disease, receiving symptom relief, comfort, and support and medical therapy are preferred.

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Will California Opt for the Public Option?

Wednesday, March 7th, 2012

Although Vermont became the first state in the union to adopt a public option in healthcare, it may soon have company.  As Vermont Governor Peter Shumlin said when signing the legislation, “We gather here today to launch the first single-payer healthcare system in America, to do in Vermont what has taken too long – have a healthcare system that is the best in the world, that treats health care as a right and not a privilege, where health care follows the individual, isn’t required by an employer –  that’s a huge jobs creator,” Shumlin said.

The enormity of creating a public option hasn’t stopped tiny Vermont, which might seem like an unlikely place for a major revamp of the health insurance system: “By most standards, Vermont’s health care system already is one of the nation’s best. The United Health Foundation has ranked Vermont the healthiest state in the country four years in a row. Fewer than 10 percent of Vermonters lack health insurance, one of the lowest rates in the country.”

And then there’s California.  In a giant warehouse in Alameda, an army of  phone operators are employed by a large health insurance plan, and they’re willing to go the extra mile for their customers. They’ll schedule a doctor who will make home visits, a pharmacist who will drop off a prescription, and even help fill out an application for food stamps.  “We do things for them that a traditional, commercial health plan doesn’t do,” says Ingrid Lamirault, chief executive officer of the Alameda Alliance for Health, a county-run, not-for-profit insurer.

Although the much celebrated, and much maligned, public option may have died in Congress, it’s alive and well in California, which is unique in the nation for having public health insurance plans that are run by its counties.  California’s plans stretch from San Francisco to the Mexican border and cover 2.5 million residents.

The Alameda Alliance for Health – like a private insurance company — has a network of doctors and hospitals and covers 200,000 people in Oakland and neighboring communities.  Much like private health insurance companies, the alliance also runs a managed care plan for Medicaid beneficiaries and additional plans for county workers.   The alliance’s Lamirault thinks this is just the beginning.  In 2014, when the Patient Protection and Affordable Care (ACA) becomes law, millions of Americans will be able to buy coverage through state-based insurance exchanges. In California, government-run public plans, like the Alameda Alliance for Health, will compete with private insurance companies for all those new customers, those who run the county plans believe they can offer a robust network of doctors and hospitals to bargain shoppers looking for affordable coverage. “I think when some people get to make a choice,” according to Lamirault, “having local offices they can walk into and get help with things and get their questions answered, and when they call customer service they get their calls answered in under two minutes. Those kinds of things are important to them.”

California is unique in that many public county systems also contract with private physicians and top-notch research hospitals. They even share the same lobbying group as the big-named insurance companies, the California Association of Health Plans.  Some of those companies don’t have a lot of love for their public brethren. “Certainly, there are some health plans that didn’t like the idea of having to compete with these public plans,” said Anthony Wright, a public plan booster and executive director of Health Access, a Sacramento-based health care consumer advocacy group. “Especially ones that, having come out of the Medicaid program, are used to providing care at cheaper rate.”

Some California insurance companies say they will happily compete on price so long as the public plans do not get preferential treatment.  Doctors and hospitals already accept low reimbursement rates from public plans, often as part of their charity care. That lets the public plans keep their premiums low, although private plans say they are charged higher prices.

The preferential treatment is not likely to last beyond the 2014 opening of the exchanges in California to people with higher incomes, the government-run plans will have to pay providers more than they do now, according to Sumi Sousa, officer of policy development at the San Francisco Health Plan. Sousa says the belief that public plans always cost less just isn’t true. “Some commercial providers, because they’re so large, they’re able to spread their cost over a much broader network,” Sousa said. That’s not the case for many county-run health plans in California, which are quite small.  Still, says Sousa, the public plans do have low overhead: Executives earn a fraction of the salary paid to the big CEOs, and they have no stockholders.

Additionally, the public option is likely to be on California’s 2012 ballot.   Jamie Court, executive director of Consumer Watchdog, a Santa Monica-based consumer advocacy group, plans to put an initiative to add a state-run healthcare public option on the ballot. Opponents say the initiative doesn’t improve the way healthcare is delivered and paid for.  Despite critics, Court says he’ll push forward on his plans to circulate a petition to the public.  “We believe the premium regulation is definitely something that Californians overwhelmingly favor, and we think the public option is something that they still favor,” Court said.  Court has written that health insurance requirements are a motivating force for the initiative: “By 2014, all of us will be required to buy health insurance or face tax penalties. The problem is that health insurance companies can charge whatever they like and raise premiums at will in California.”

In opposition, Micah Weinberg of the Bay Area Council, say rising rates reflect rising health care costs and extended life spans, and the government should let competition keep rates down. Weinberg calls himself an “enthusiastic supporter of healthcare reform,” and argued on KPCC’s Patt Morrison Tuesday that the system is already making reforms — reforms he feels the public option doesn’t address.  “We’re expanding insurance coverage by giving people insurance subsidies to purchase insurance through the exchanges, so that’s exactly what we’re doing.  A public option doesn’t get us any closer to that goal and it’s not a helpful addition to what we’re trying to accomplish,” says Weinberg.

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The Primary-Care Challenge

Tuesday, March 6th, 2012

The Obama administration has committed $9.1 million in National Health Service Corps awards for medical students who sign up to serve in underserved areas.  The funding, which was made possible by the Patient Protection and Affordable Care Act (ACA), provides loan repayment assistance of up to $120,000 to fourth-year medical students if they commit to serve in a “health professional shortage area” upon completion of a primary care residency program.  “This new program is an innovative approach to encouraging more medical students to work as primary care doctors,” Health and Human Services Secretary Kathleen Sebelius said.  “This is an important part of the Administration’s commitment to building the future health care workforce.”

The United States is facing a shortage of 21,000 primary-care doctors just three years from now, according to the Association of American Medical Colleges.  The most important reason is that primary care doctors earn significantly less that specialists, despite having substantial student debt.  “The average medical school debt of the students receiving these awards is more than $200,000,” said Mary Wakefield, administrator of the Health Resources and Services Administration.  “The Students to Service program relieves a tremendous debt burden, allowing them to follow their passion for primary care and serve some of the country’s most underserved rural and urban communities.”

Even though medical students entering primary care residencies rose 20 percent from 2009 to 2011, according to the Association of American Medical Colleges, trying to make workforce gains in primary care is certainly no small feat.  The primary-care specialty is contending with a number of factors that aren’t helping to boost primary-care physician numbers.

“No matter what specialty you’re going into, your medical education costs the same,” American Academy of Family Physicians President Glen Stream said.  “Think about a medical student who is sort of interested in primary care and has got $250,000 in debt.  People are often driven by financial incentives, and you basically get the outcome that you incent.  Healthcare workforce is not different from any other sector in that regard.”  While a primary-care physician could earn $101 in Medicare reimbursements every hour, a hospital radiologist might earn $193.

Administered by HHS’ Health Resources and Services Administration (HRSA), Students to Service is a pilot program that provides loan repayment assistance of up to $120,000 to medical students (both M.D. and D.O. degrees are covered) during their final year of education.  In return, they commit to serve three years of full-time service or six years of half-time service in rural and urban areas of greatest need once they complete their primary-care residency program.

According to Martin Kramer, HRSA’s director of communications, “Essentially, this program not only encourages students to join NHSC but it also encourages them to go into primary care.  HHS Students to Service Program participants must work at NHSC-approved sites in federally designated Health Professional Shortage Areas (HPSAs) of greatest need throughout the United States.  Annual payments of up to $30,000 will be made over the course of four years, beginning in the participant’s first year of residency,” Kramer said.  “With continued service, eligible providers may be able to pay off all qualifying student loans.”  To be considered for the loan, students submitted an application to the NHSC, which were then rated by an independent review committee.  “Awardees had to demonstrate the characteristics for and interest in serving the nation’s medically underserved populations,” he said.  “By law, priority was also given to applicants from disadvantaged backgrounds.”

Writing on the KevinMD.com website, Maggie Mahar suggests that more primary-care physicians might not be the panacea that healthcare needs. “The emphasis on primary care as the ‘key’ to lifting the quality of U.S. healthcare may be exaggerated according to a report by Dartmouth’s Institute for Health Policy & Clinical Practice.  ‘Primary care forms the bedrock of a well-functioning, effective healthcare system,’ the researchers observe.  But– and this is an important caveat- ‘simply increasing access to primary care, either by boosting the number of primary-care physicians in an area or by ensuring that most patients have better insurance coverage, may not be enough to improve the quality of care or lead to better outcomes.’  Wait a minute.  In past reports, didn’t Dartmouth’s researchers tell us that patients fare better if they see fewer specialists and more internists?

“No.  Dartmouth’s earlier studies have shown that when patients see more specialists, care is more aggressive and more expensive, but, on average, outcomes are no better — and sometimes they are worse.  This, however, doesn’t mean that primary care, by itself, ensures better care, even if a patient sees her primary-care physician on a regular basis.  As the report points out: ‘Primary care is most effective when it is embedded in a high-functioning system, where care is coordinated, where physicians communicate with one another about their patients, and where feedback is available about performance that allows physicians and local hospitals to continually improve.’  Policy should ‘focus on improving the actual services primary care clinicians provide and making sure their efforts are coordinated with those of other providers, including specialists, nurses and hospitals,’  said Dr. David C. Goodman, lead author and co-principal investigator for the Dartmouth Atlas Project.

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